AJR 2001; 176:381-386
© American Roentgen Ray Society
Lateral Radiography of the Cervical Spine in the Trauma Patient
Looking Beyond the Spine
Jonathan R. Perry1,
Eric J. Stern,
Frederick A. Mann and
Alexander B. Baxter
1
All authors: Department of Radiology, Harborview Medical Center of the
University of Washington, Box 359728, Seattle, WA 98104.
Received March 13, 2000;
accepted after revision July 7, 2000.
Presented at the annual meeting of the American Roentgen Ray Society, New
Orleans, May 1999.
Address correspondence to E. J. Stern.
Introduction
In the traumatized patient, the cross-table lateral cervical spine
radiograph is commonly obtained immediately on arrival in the emergency
department, along with a chest radiograph and pelvis radiograph. These three
radiographs—the trauma series—are obtained to rapidly screen for
life-threatening injuries. With the cervical spine radiograph, there is a
tendency to focus on the spine itself. The careful observer can find other
clues to injuries that are exclusive of the spine. Although many of these
injuries are better evaluated with other imaging modalities, careful study of
the lateral cervical spine radiograph can allow earlier detection and
intervention of many serious injuries. This pictorial essay will show a
spectrum of radiographic findings that can be seen when one looks beyond the
spine itself.
Tube Malposition
Esophageal intubation occurs in 5-10% of initial intubations
[1]. Neither physical
examination nor carbon dioxide monitoring can always reveal esophageal
intubation. Thus, recognizing misplacement as soon as possible is critical
[2,
3]. In the appropriate clinical
setting, verification of proper endotracheal tube position should be a
standard part of the radiographic evaluation. Signs of esophageal intubation
on the lateral radiograph of the cervical spine include recognition of the
laryngeal air column anterior to the endotracheal tube (Fig.
1A,1B),
apparent decrease of prevertebral soft-tissue width, and overdistention of the
endotracheal balloon; because the esophagus lacks cartilaginous rings to
constrain the endotracheal balloon, esophageal intubation can lead to balloon
overdilatation. Balloon diameters greater than the tracheal diameter strongly
suggest improper tube location, such as esophageal or pharyngeal placement, or
rupture of the trachea [2,
3]. Esophageal intubation can
be difficult to detect on the anteroposterior chest radiograph because the
misplaced endotracheal tube often projects over the midline in the expected
position of the trachea
[3].
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Fig. 1A. —14-month-old boy involved in motor vehicle crash. Lateral
cervical spine radiograph shows endotracheal tube directly apposing cervical
vertebral bodies, with absence of usual precervical soft-tissue density from
C3 inferiorly. Air fills anteriorly displaced trachea (arrow). Note
nasogastric tube coiled in mouth and pharynx.
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Fig. 1B. —14-month-old boy involved in motor vehicle crash.
Anteroposterior supine chest radiograph shows gaseous distention of esophagus
and stomach, which is further evidence of esophageal intubation.
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An improperly placed nasogastric tube (in the trachea or coiled in the
pharynx or esophagus) increases the risk of aspiration (Figs.
2 and
3) and may also be visible on
the lateral cervical spine radiograph. Likewise, the nasogastric tube can be
misplaced into the cranium in patients with basilar skull fracture or in those
who have undergone prior neurosurgical intervention (e.g., transsphenoidal
pituitary tumor resection).
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Fig. 3. —58-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows nasogastric tube (arrow) positioned
anterior to endotracheal tube in airway; this finding was confirmed by chest
radiograph (not shown).
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Fractures of the Mandible
The mandibular angle and ramus are usually well visualized on the lateral
cervical spine radiograph. Up to 50% of mandible fractures are bilateral
[4]. Either the free-floating
mandibular symphysis fragment or the tongue (in cases of flail mandible) can
be displaced posteriorly and occlude the airway
[5] (Figs.
4 and
5). It is particularly
important to detect these fractures in patients whose airways are not
protected. In addition, patients with mandible fractures have an increased
incidence of injuries to the upper cervical spine
[6].
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Fig. 4. —75-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows bilateral comminuted fractures of mandible
(arrows), involving body, angle, and ramus. Also, note swallowed
debris (arrowhead).
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Fractures of the Face and Skull
Fractures of the face and skull are associated with both intracranial
injury and cervical spine fracture
[7,8,9].
Their rapid detection on the trauma series can have an immediate impact on the
selection of further imaging of the head and cervical spine. Patients with
facial fractures are twice as likely to have cervical spine fractures, and
patients with skull fractures are nearly 10 times more likely to have cervical
spine fractures [8]. In
addition, patients with cervical spine injuries have a higher incidence of
intracranial injury [9].
Fractures of the face and skull can be diagnosed on the lateral cervical
spine radiograph because variable portions of the face and skull are included
(Figs.
6A,6B,7A,7B,7C,8,9,10A,10B,10C).
Fractures of the posterior walls of the maxillary sinus and the pterygoid
plates indicate a Le Fort's fracture. Le Fort's fractures can also cause
prevertebral soft-tissue swelling that may lead to airway compromise. A
sphenoid air-fluid level indicates a skull base fracture, which is associated
with carotid cavernous fistula. Transverse fractures of the hard palate are
associated with laceration of the palatine arteries, which can lead to
anterior cervical hematoma and occlusion of the airway
[5].
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Fig. 6A. —26-year-old woman involved in motor vehicle crash. Lateral
cervical spine radiograph shows diagonal fracture (arrow) across
temporal and parietal bones. Temporal bone fracture has increased risk of
middle meningeal artery injury.
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Fig. 7B. —58-year-old man involved in motor vehicle crash. Axial CT
scan shows extension of temporal fracture (arrow) into right mastoid
process of temporal bone. Fractures can be seen through both lateral walls of
sphenoid sinus (arrowheads). Mastoid air cells and sphenoid sinus are
opacified from hemorrhage.
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Fig. 7C. —58-year-old man involved in motor vehicle crash. Axial CT
scan obtained at more cephalad level than B shows intraparenchymal
hemorrhage adjacent to fracture, subarachnoid hemorrhage in interpeduncular
cistern, and subarachnoid or subdural hemorrhage along tentorium
cerebelli.
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Fig. 8. —55-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows horizontal fracture of sphenoid and temporal
bones (arrow) that intersects with oblique fracture of sphenoid and
parietal skull (arrowhead).
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Fig. 10A. —45-year-old woman involved in motor vehicle crash. Lateral
cervical spine radiograph shows air-fluid levels in maxillary sinuses
(arrowheads), consistent with hemorrhage from fracture. There are
fractures of frontal skull, frontal sinuses, and supraorbital ridges
(arrows).
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Pneumocephalus
Traumatic pneumocephalus is usually caused by the introduction of air from
a fracture of a sinus, from the mastoid air cells, or from an open skull
fracture (Figs.
11A,11B
and
12A,12B).
Pneumocephalus can be epidural, subdural, subarachnoid, parenchymal, or
intraventricular. Subdural pneumocephalus points to fractures of the anterior
fossa or the upper face (frontal and ethmoid sinuses), because dura mater in
these locations may be more adherent to the skull than the underlying
arachnoid. Subarachnoid pneumocephalus points to basilar skull and sphenoid
fractures (sphenoid sinus and mastoid air cells), because dura and arachnoid
are more closely adherent to each other in these locations
[10]. Once a patient is placed
supine on a backboard, gas percolates anteriorly as far as it can from its
point of introduction. Thus, often the best place to look for pneumocephalus
on the cross-table lateral cervical radiograph is adjacent to vertical
anterior structures. Pneumocephalus will commonly be seen as vertically
oriented crescentic lucencies posterior to the orbits and the frontal sinus.
Gas within the sub-arachnoid space will outline gyri (low-contrast vermiform
lucencies) or be found more centrally within cisterns. Subarachnoid
pneumocephalus can sometimes extend into the spinal subarachnoid space and
outline the cord [11].
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Fig. 11A. —45-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows linear lucencies posterior to orbits
(arrows), representing pneumocephalus. Fracture of maxillary sinus is
indicated by disruption of posterior wall and air-fluid level
(arrowheads).
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Fig. 12A. —20-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows lucency posterior to clinoid processes
(arrow) and maxillary sinus air-fluid level
(arrowheads).
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Fig. 12B. —20-year-old man involved in motor vehicle crash. Axial CT
scan shows pneumocephalus in prepontine cistern and left middle cranial fossa
and fractures of sphenoid sinus and left lateral orbital wall.
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Laryngotracheal Injuries
Calcification of the thyroid cartilage occurs in many adults and makes it
possible to diagnose fractures on conventional radiography
(Fig. 13). Laryngotracheal
separation or dislocation and multiple fractures of the tracheal rings are
emergent injuries and require intubation or tracheostomy. Injuries that can be
treated expectantly include simple fractures of the hyoid bone and fracture of
the superior cornu of the thyroid cartilage. Signs of laryngotracheal injuries
include abnormal enlargement of the endotracheal tube balloon, abnormal
endotracheal tube location, and parapharyngeal soft-tissue emphysema (Figs.
14A,14B
and
15A,15B,15C).
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Fig. 13. —53-year-old woman struck in neck with baseball bat. Lateral
cervical spine radiograph shows calcified thyroid cartilage fractured into
several fragments (arrowheads). Air tracks can be seen superiorly in
cervical soft tissues (arrow), suggesting adjacent laceration.
Patient's airway is at risk indirectly from loss of supportive structure of
thyroid cartilage and directly from compromise of laryngeal aditus and
hematoma from injury.
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Fig. 14A. —57-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows gas tracking along multiple fascial planes in
prevertebral soft tissues (arrowheads). Endotracheal tube balloon
(double arrow) is larger than tracheal cartilage and cricoid
cartilage internal diameters, suggesting it is not confined by either.
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Fig. 14B. —57-year-old man involved in motor vehicle crash.
Anteroposterior supine chest radiograph shows endotracheal tube tip deviating
to right (single arrow), but tracheal air column continues midline.
Lower portion of endotracheal tube balloon is seen at level of C7 and is
over-expanded (double arrow). Pneumomediastinum is present and
extends into fascial planes of neck.
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Fig. 15A. —18-year-old unrestrained male driver involved in head-on
motor vehicle crash. Cross-table lateral cervical spine radiograph shows
retropharyngeal emphysema (arrow). Chest radiograph (not shown)
showed neither pneumomediastinum nor pneumothorax.
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Fig. 15B. —18-year-old unrestrained male driver involved in head-on
motor vehicle crash. Axial CT scan through neck shows left-sided posterior
oropharyngeal laceration and adjacent retropharyngeal emphysema
(arrow).
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Fig. 15C. —18-year-old unrestrained male driver involved in head-on
motor vehicle crash. Axial CT scan at more caudal level than B shows
parapharyngeal hematoma nearly completely effacing left vallecula
(arrow).
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Soft-tissue emphysema in the neck is typically prevertebral and results
from barotrauma, with extension of air from the mediastinum
(Fig. 16). Laryngotracheal
fractures and laryngeal lacerations are associated with parapharyngeal
soft-tissue emphysema.
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Fig. 16. —60-year-old man involved in motor vehicle crash. Lateral
cervical spine radiograph shows prevertebral emphysema (arrowheads).
This finding is often from barotrauma-induced pneumomediastinum tracking
superiorly but can also be caused by laceration of trachea, pharynx, or
esophagus.
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Airway Compromise from Soft Tissue and Debris
The patient's airway can be compromised by swelling and hematoma (Fig.
15A,15B,15C),
from soft-tissue injury [5] or
cervical spine fracture, and as a result of aspiration of dental fragments or
other debris (Fig. 17).
Recognition of airway compromise and impending insufficiency before clinical
deterioration can be life-saving. Discovery of fractured or missing teeth
necessitates a careful search of the chest radiograph for aspirated dental
debris because it should be removed bronchoscopically within 24 hr to prevent
postobstructive pneumonitis and bronchostenosis.
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Fig. 17. —44-year-old man involved in fistfight. Lateral cervical spine
radiograph shows high-density material in pharynx (arrow) that
represents either aspirated debris or dental-filling fragments.
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Conclusion
The lateral cervical spine radiograph is a powerful tool in the trauma
setting, and its utility increases if the observer looks beyond the spine to
recognize other fractures, tube misplacements, and other evidence of trauma
and disease.
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Introduction
Tube Malposition
